Introduction to Introduction to MyofascialMyofascial Trigger Point Trigger Point

AcupunctureAcupuncture

--An Evidence Based Needling An Evidence Based Needling MethodMethod

What is a What is a MTrPMTrP??

►►A point of tenderness in a muscle.A point of tenderness in a muscle.►►Stimulation of Stimulation of MTrPMTrP may cause pain at a may cause pain at a

remote remote region.remote remote region.►►Often associate with a taut band in a muscle.Often associate with a taut band in a muscle.

Causes of Causes of MTrPMTrP

►►Trauma to muscleTrauma to muscle►►Muscle Muscle ischaemiaischaemia►►VisceralVisceral--somatic reflexsomatic reflex►►RadiculopathicRadiculopathic compression of nerve rootcompression of nerve root►►AnxietyAnxiety►►Others possible causesOthers possible causes

MTrPMTrP Related Taut BandRelated Taut Band

►►MTrPMTrP usually situated at the centre or usually situated at the centre or terminal of a taut bandterminal of a taut band

►►The band disappears when the The band disappears when the MTrPMTrP is is deactivated.deactivated.

►►Caused by Caused by dysfunctioningdysfunctioning motor endplate / motor endplate / local local ischaemiaischaemia..

►►Taut bandTaut band→→Latent Latent MTrPMTrP →→Active Active MTrPMTrP

Local Twitch Response (LTR)Local Twitch Response (LTR)

►►Essentially a spinal reflexEssentially a spinal reflex►►Stimulation via a sensitized afferent Stimulation via a sensitized afferent →→

elicited reflex motor efferent response.elicited reflex motor efferent response.►►Essential for diagnosis and treatmentEssential for diagnosis and treatment

Diagnosis of Diagnosis of MTrPMTrP SyndromeSyndrome

►►SymptomsSymptomsPainPainRestricted movementRestricted movement►►Can be symptom or signCan be symptom or sign

WeaknessWeakness►►Can be symptom or signCan be symptom or sign

Sleep disturbanceSleep disturbancePeripheral hypothermiaPeripheral hypothermia

Diagnosis of Diagnosis of MTrPMTrP SyndromeSyndrome

►►Physical SignsPhysical Signs““JumpJump”” or or ““ShoutShout”” signsignPain ReproductionPain ReproductionPalpable Taut BandPalpable Taut BandLocal Twitch ResponseLocal Twitch ResponseCutaneousCutaneous & Subcutaneous tissue thickening& Subcutaneous tissue thickening

IntertestersIntertesters reliabilityreliability

►►Reliability and consistence can be Reliability and consistence can be improved through experience and improved through experience and training. training.

►►Cardinal signs are:Cardinal signs are:TendernessTendernessTaut band*Taut band*Local Twitch Response*Local Twitch Response*Referred PainReferred Pain

The Pain Gate MechanismThe Pain Gate Mechanism

►► ““Stimulation of the large Stimulation of the large fibresfibres can close the gate can close the gate for transmission of the smaller for transmission of the smaller fibresfibres..””

►► Skin / Muscle Skin / Muscle NociceptorsNociceptorsAA--delta fiber, Group III delta fiber, Group III nociceptorsnociceptors►►MyelinatedMyelinated, 1, 1--5um, 55um, 5--15m/s15m/s

C C fibrefibre, Group IV , Group IV nociceptorsnociceptors►►UnmyelinatedUnmyelinated, 0.25, 0.25--1.5um, 0.51.5um, 0.5--2m/s2m/s

Pain Modulation MechanismPain Modulation Mechanism

Pain Modulation MechanismPain Modulation Mechanism

►► Endogenous PainEndogenous Pain--suppressing Substancesuppressing SubstanceOpiate receptorsOpiate receptors►►Widely distributed in the brain and spinal cordWidely distributed in the brain and spinal cord►►Their presence, indicate the existence of the endogenous Their presence, indicate the existence of the endogenous opioidopioid

peptides.peptides.

OpioidOpioid peptidespeptides►►MorphineMorphine--like substance, like substance, ►►EnkephalinsEnkephalins & & dynorphinsdynorphins mainly at limbic structure, mainly at limbic structure,

periadqueductperiadqueduct grey area, nucleus grey area, nucleus rapheraphe magnusmagnus, , substantiasubstantiagelatinosagelatinosa →→ CSFCSF

►►ßß--endophineendophine secreted from adrenal gland, gut, sympathetic secreted from adrenal gland, gut, sympathetic ganglia, peripheral autonomic neurons ganglia, peripheral autonomic neurons →→ BloodBlood

Needling on Needling on MTrPMTrP

►►Wet Needle Vs. Dry NeedleWet Needle Vs. Dry Needle►►Needling action is the Key pointNeedling action is the Key point

►►Deep dry needling Vs Superficial dry Deep dry needling Vs Superficial dry needlingneedling

Deep Dry NeedlingDeep Dry Needling

►►A painful techniqueA painful technique►►Insert the needle rapidly into the Insert the needle rapidly into the MTrPMTrP►►Elicit the Local Twitch Response (LTR) or Elicit the Local Twitch Response (LTR) or

soreness / swollen sensation / radiation to soreness / swollen sensation / radiation to the affected area.the affected area.

►►Needle ManipulationNeedle Manipulation►►After treatment sorenessAfter treatment soreness

Superficial Dry NeedlingSuperficial Dry Needling

►►The needle is just subcutaneous, right over The needle is just subcutaneous, right over the the MTrPMTrP..

►►Working mechanism:Working mechanism:Activate Activate EiEi interneuroninterneuronDescending inhibitory systems and DNICDescending inhibitory systems and DNIC

Superficial Dry NeedlingSuperficial Dry Needling

Insertion of superficial dry needleInsertion of superficial dry needle↓↓

Stimulation of AStimulation of A--delta sensory delta sensory fibrefibreDoral hornDoral horn--situated situated enkephalinergicenkephalinergic inhibitory interneuroninhibitory interneuron

SerotonergicSerotonergic & Noradrenergic descending systems& Noradrenergic descending systems↓↓

Blockage of the intraBlockage of the intra--dorsal horn passage of dorsal horn passage of MTrPMTrP nociceptivenociceptiveinformationinformation

↓↓

Alleviation of Alleviation of MTrPMTrP painpain

Superficial Dry NeedlingSuperficial Dry Needling

►►Minimal sensation techniqueMinimal sensation technique►►2 methods:2 methods:

PerpendicularPerpendicularhorizontalhorizontal

►►Perpendicular:Perpendicular:Pointing to the Pointing to the MTrPMTrP,,Insert for 5Insert for 5--10mm10mmNeedle manipulationNeedle manipulation

Superficial Dry NeedlingSuperficial Dry Needling

►►Horizontal:Horizontal:Horizontally at the Horizontally at the subcutaneous tissue subcutaneous tissue right over the right over the MTrPMTrPNeedle manipulationNeedle manipulation

Treatment for Treatment for MTrPMTrP SyndromeSyndrome

1.1. Assessment: locate the active / latent Assessment: locate the active / latent MTrPMTrP’’ss

2.2. Deactivate the Deactivate the MTrPMTrP3.3. Stretching to the affected muscleStretching to the affected muscle4.4. Advice on correction and preventionAdvice on correction and prevention

Clean Needle TechniqueClean Needle Technique

►► ReferenceReferenceClean Needle Technique Manual for AcupuncturistClean Needle Technique Manual for Acupuncturist

Guideline and Standard for the Clean and Safe Guideline and Standard for the Clean and Safe Clinical Practice of AcupunctureClinical Practice of Acupuncture

5th Edition.5th Edition.

www.aomalliance.orgwww.aomalliance.org

Need for CNTNeed for CNT

►►Needling treatment always has potential Needling treatment always has potential infection hazard.infection hazard.

►►Good knowledge in transmission and Good knowledge in transmission and prevention of infection, e.g. hepatitis, HIV.prevention of infection, e.g. hepatitis, HIV.

Recommendations for EquipmentRecommendations for Equipment

►► Use only: sterile, Use only: sterile, filiformfiliform (solid), disposable (solid), disposable needles.needles.

►► Appropriate needle package.Appropriate needle package.►► Avoid contamination in needle removal from the Avoid contamination in needle removal from the

package.package.►► Proper disposal of used needles.Proper disposal of used needles.►► Cupping devices must be sterilized in chemical Cupping devices must be sterilized in chemical

disinfectant bath after in contact with patientdisinfectant bath after in contact with patient’’s s blood. Otherwise, wash with soap and running blood. Otherwise, wash with soap and running water.water.

General GuidelineGeneral Guideline

►► Patient positioning:Patient positioning:Comfortable and suitable for needling.Comfortable and suitable for needling.

►► Preparing the site for needle insertion:Preparing the site for needle insertion:The area should be clean, free of any cuts, wound The area should be clean, free of any cuts, wound or disease, or disease, Use 70% alcohol to disinfect the skin,Use 70% alcohol to disinfect the skin,

►► Palpating the point:Palpating the point:It is acceptable to touch the It is acceptable to touch the acupointacupoint after after cleaning, with uncontaminated hand. cleaning, with uncontaminated hand. Swabbing the acupuncturistSwabbing the acupuncturist’’s fingertips can be a s fingertips can be a substitute to the second substitute to the second handwashhandwash..

Shoulder Pain 1Shoulder Pain 1

►►SupraspinatusSupraspinatusMuscleMuscle

►►MTrPMTrP & referred pain:& referred pain:→→ deltoid region, deltoid region, →→ lateral lateral epicondyleepicondyle, ,

similar to the similar to the distribution of C5distribution of C5--C7.C7.

Shoulder Pain 2Shoulder Pain 2

►► InfraspinatusInfraspinatus MuscleMuscle►► MTrPMTrP & Referred Pain:& Referred Pain:→→ deep inside the deep inside the shoulder jointshoulder joint→→ similar to the C5similar to the C5--C7 C7 distribution in the arm.distribution in the arm.

►► Difficulty in HandDifficulty in Hand--behindbehind--backback

Shoulder Pain 3Shoulder Pain 3

►► Biceps Biceps BrachiiBrachii MuscleMuscle►► MTrPMTrP & Referred Pain& Referred Pain

MTrPMTrP usually at the usually at the lower portion of the lower portion of the musclemuscle

→→ Pain referred upward Pain referred upward to the anterior surface to the anterior surface of the shoulder.of the shoulder.

►► Biceps TendinitisBiceps Tendinitis

Points to be notedPoints to be noted

►►Sound anatomy & pain physiology Sound anatomy & pain physiology ►►Stimulation should be within patientStimulation should be within patient’’s pain s pain

tolerance.tolerance.►►All All MTrPMTrP’’ss should be treated in the same should be treated in the same

sessionsession►►Stretch after needlingStretch after needling►►Tender spot Vs Tender spot Vs MTrPMTrP